The uptake of key Essential Nutrition Action (ENA) messages and its predictors among mothers of children aged 6–24 months in Southern Ethiopia, 2021: A community-based crossectional study

Background Essential nutrition action(ENA) is a framework for managing advocacy, establishing a foundation, and implementing a comprehensive package of preventive nutritional activities. Essential Nutrition Actions study studies provide current information on each nutrition action, allowing health systems to focus more on nutrition, which is critical in tackling the “double burden” of malnutrition: underweight and overweight. Hence, this study aimed at assessing the level of ENA practice and its predictors among mothers of children aged 6 to 24 months in southern Ethiopia. Methods A community-based cross-sectional study was conducted from May 1 to 30, 2021 among randomly selected 633 mothers of children aged 6–24 months. A multi-stage sampling technique was used to access study participants. Data were collected by using a pretested, structured interviewer-administered questionnaire. To identify predictors of ENA practice, bivariable and multivariable logistic regression were used. The strength of the association was measured using an adjusted odds ratio with 95 percent confidence intervals. The statistical significance was declared at a p-value less than 0.05. Results A total of 624 participants took part in the study, with a response rate of 98.6%. The uptake of key ENA messages among mothers was measured using 27 items, and it was found to be 47.4% (95% CI: 43.8, 51.4). Complementary feeding was the commonest ENA message practiced by 66.7% of respondents, while prevention of iodine deficiency disorder was practiced by only 33.7% of respondents. Variables namely, mother’s education level of college and above [AOR: 3.90, 95% CI: 1.79, 8.51], institutional delivery [AOR: 2.75, 95% CI: 1.17,6.49], having PNC service [AOR: 2.95, 95% CI: 1.91, 4.57], being knowledgeable on ENA message [AOR: 2.37, 95% CI: 1.81, 3.26] and being a model household [AOR: 3.83,95% CI: 2.58, 5.69] were positively associated with a good uptake of key ENA messages. On the other hand, primiparity [AOR: 0.32, 95% CI: 0.21,0.56] was identified as a negative predictor. Conclusion The overall practice of key Essential nutrition action messages in the study area was low as compared to studies. Stakeholders must step up their efforts to improve and hasten the utilization of maternal and child health services, especially institutional delivery and Postnatal care by focusing on uneducated women to promote compliance to key ENA messages. Furthermore, health workers need to focus on awareness-raising and model household creation. A community-based cross-sectional study was conducted in the Lemo District from May 1 to 30, 2021. The district is located 232 kilometers from Addis Ababa, Ethiopia’s capital city, and 15 kilometers from Hossana, the Hadiya zone’s capital. The total population in the district, based on the 2007 Central Statistics Agency estimation, is 118,594 (Male = 58,666 and Female = 59,928). There are a total of 35 kebeles in the district, (Kebele: the smallest administrative unit in the current Ethiopian government structure under the district). The primary health care units offering maternal and child health services were five health centers, one non-profitable non-governmental clinic, and 35 health posts (one in each kebele). The source populations were all mothers of children aged 6 to 24 months in the Lemo district. Mothers with children aged 6–24 months in the selected kebeles of the district constituted the study population. Mothers who resided in the study area for at least six months were included, whereas those who were extremely ill during the data collection period were excluded. The study sample size for the study was determined by using the single population proportion formula via the StatCalc menu of Epi-info version 7. The following parameters were used: estimated prevalence of ENA of 46.5%, taken from a similar study conducted in northern Ethiopia [26], a 95% confidence interval, 5 percent degree of precision, design effect of 1.5, and non-response rate of 10%. The final sample size for the study was 633. A multi-stage sampling procedure was used to access study participants. Of 35 kebeles, fourteen were selected using a simple random sampling technique. Using the registration logbook of health extension workers, households with mothers of children aged 6–24 months were identified. Codes/numbers were then assigned to those houses that had eligible study participants, and a sampling frame was formed. The required sample size for each kebele was allocated by using a proportional allocation. By using a computer-generated random number study participants were selected and interviewed. Re-visits were made three times if selected respondents were difficult to access at the time of the survey. A pretested, interviewer-administered questionnaire was used for the data collection. Eight diploma nurses with prior data collection experience conduct the data collection under the supervision of four public health officers. The data collection tool was developed by using the 2013 WHO Guideline for Essential Nutrition Actions, Enhancing Health and Nutrition for Maternal, Baby, Infant, and Young Children, Food and Agriculture Organization (FAO), and related literature [1, 7, 26, 27]. It was designed in the way to collect data on socio-demographic/economic, obstetric, and health system-related characteristics, exclusive breastfeeding, complementary feeding, sick child feeding, nutrition during pregnancy and lactation, vitamin A deficiency prevention, anemia prevention, and iodine deficiency prevention. Supervisors and data collectors were guided to sampling women’s homes by the local Health Development Army (HDA) and community volunteers in each Kebele, and the respondents were then interviewed at their residential homes. Data collectors and supervisors got a one-day intensive training on data collection methods and procedures. The data collection tool was prepared in English, then translated into the local language (Amharic) by experts in that language, and finally back-translated to English to ensure that it fit the original meaning. A pre-test was conducted in the Soro district one week before the actual data collection for 5% of the sample size (29 women). To avoid any confusion, all necessary modifications were made based on the pre-test results. Supervisors and investigators closely oversaw the data collection processes daily to ensure the quality of the data. Investigators checked for missing values, inconsistencies, and outliers, and the possible corrections were made during the data collection period. Study participants were interviewed in private to reduce social desirability bias. To minimize the likelihood of recall bias respondents were given as much time as they needed for a good recall of long-term memories. In addition, inquiries were made, following an ordered sequence of events—starting with the present and thinking back to a point in time to cope with the recall bias. Epi-data version 3.1 was used to enter the data, which was then exported to SPSS version 23.0 for analysis. Inconsistencies and missing values were examined using running frequencies. Frequency distributions, mean, and standard deviation have all been computed as descriptive statistics. The wealth status of households was determined using principal component analysis (PCA). Initially, 29 items were used and categorized into six categories: household property, livestock ownership, crop production in quintals, average monthly estimated income, agricultural land in hectares, and housing conditions [15]. PCA assumptions for sampling adequacy of individual variables were confirmed, including overall sampling adequacy calculation (KMO>0.6), anti-image correlations (> 0.4), and Bartlett Sphericity Test (p-value 0.05). Finally, three components were selected from the PCA, and the first component accounting for the maximum variation (48.9%) was used to classify the study participants’ wealth status into quintiles [15]. To examine the relationship between outcome and explanatory variables, bivariable and multivariable logistic regression were conducted. Explanatory variables with a p-value <0.25 in the bivariable analysis were simultaneously moved into a multivariable logistic regression model to control for potential confounders. Those variables with a p-value< 0.05 in the final model were identified as determinants of ENA practice. Finally, the regression analysis findings have been reported using their adjusted odds ratios and the corresponding 95% confidence interval. Reports were presented in the form of charts, graphs, and figures. The statistical significance was declared at a p-value less than 0.05. The model fitness was assessed by using Hosmer and Lemeshow test, and the P-value was 0.521, indicating that the model provided the best fit. The level of multicollinearity was also examined using standard error cut-off two, but no multicollinearity was found among the variables studied. Essential Nutrition Action (ENA): is an integrated preventive nutrition package comprising seven core components namely; exclusive breastfeeding, complementary feeding, sick children feeding, nutrition for women during pregnancy and breastfeeding, vitamin A deficiency prevention, anemia prevention, and iodine deficiency prevention [5, 7, 28]. A total of 27 items were used to assess ENA practice: exclusive breastfeeding(6 items), complementary feeding(5 items), sick child feeding(4 items), nutrition for women during pregnancy and breastfeeding(3 items), prevention of vitamin A deficiency(3 items), prevention of anemia(3 items), and prevention of iodine deficiency(3 items) [1, 7, 26, 27]. Information on these items was derived from the response to the questions like: ‘Did you give sugar water, water, or butter, before breast during the first days of the baby’s life?’ For each practice assessment question, response categories were formed as ’1 = for correct response’ and ’0 = for incorrect’. A composite index of ENA practice was computed, with the lowest value of zero indicating that women did not practice any ENAs and the highest value of 27 indicating that those women practiced all ENAs. Those who scored at or above the mean were considered to have a good practice, while those who scored below the mean were considered to have poor practice [26]. Exclusive breastfeeding: If a child under the age of six months consumes only breast milk and no other food, water, or other liquids (except medicines and vitamins, if necessary) [11, 26]. Complementary feeding: introduction of additional solid or semi-solid foods starting at 6 months, along with breast milk [7, 29]. Household wealth index: Based on data from household assets and equipment, PCA was used to create a composite measure of respondents’ wealth status. Finally, the first factor, which explained the maximum variation, was divided into quintiles [15]. Knowledge of ENA: Women who attained at least the mean score for the ENA knowledge assessment questions were labeled as knowledgeable, while those who did not were labeled as not knowledgeable [26]. Perceived distance to the nearest health facility: The distance between the mothers’ residential home and the health facilities was measured in walking hours. This was categorized as ’closer’ if mothers reported walking times of less than 30 minutes to reach the nearest health facility; otherwise, it was categorized as ’far’ [30]. Being a model household (MHH): Those who have completed 75% of the four components of the health extension packages (HEPs) and have been certified [31]. These HEPs include family health (Maternal and Child Health), Infectious disease prevention and control (TB, HIV/AIDS, STIs, and Malaria), hygiene and environmental sanitation, and health education and communication [32]. Autonomy in household decision-making: A woman was said to be autonomous in decision-making if she made decisions independently or in collaboration with her husband. She was termed non-autonomous if she didn’t make the decision herself or with the will of a third party [15, 25]. Ethical clearance was obtained from the Ethical Review Committee of Wachemo University School of Public Health, College of Medicine and Health Science with Rference number of WCU/121/2013. Before the study, all subjects provided their written informed consent. Before the study, informed written consent was taken from the study participants. The Lemo District Health Office also gave an official letter of cooperation. For those respondents under the age of 18 years, assent was obtained from their parents or guardian using standard disclosure procedures. The names of the respondents were kept confidential.